Southland Hospital has been chastised again by coroner David Crerar for failing in its duty of care to an elderly patient who died last year following a motor vehicle crash.
Peter Neville Scully, of Invercargill, died in the hospital's surgical ward on August 3, just over two weeks after he failed to comply with a give-way sign at a city intersection and his vehicle was struck by another.
He had surgery a few days after the crash but deteriorated. It was found he died of pneumonia, secondary to a spinal cord injury received in the crash.
A coroner's inquest was held in Invercargill in June this year. In his formal finding released on Wednesday, Mr Crerar said Southland Hospital staff were initally reluctant to admit Mr Scully (91) to hospital and it was not until the day after the crash a CT scan revealed he had a fractured neck.
While Mr Crerar said this did not contribute to Mr Scully's death, the failure to diagnose the fracture was ''less than ideal''.
Mr Scully also suffered a spinal re-injury while in hospital, either from a fall which was not observed or not reported, or from a cough, a sneeze or a stumble, he said.
Mr Scully had been a patient at Southland Hospital several times before and staff had been told previously he reacted badly to codeine or opiates.
But staff failed to act on this advice and prescribed them anyway. Southern District Health Board chief medical officer Dr David Tulloch said at the June inquest that in the case of Mr Scully, ''the care normally given to patients at Southland Hospital did not achieve the high standard to which the hospital aspires''.
Mr Crerar said he was not satisfied from the evidence given at the inquest Mr Scully had fallen while in hospital, but there was evidence the SDHB's falls policy was not as rigidly policed as it should be.
The prescribing of codeine-type drugs was an error, he said.
''Dr Tulloch accepted that a failure by hospital staff to acknowledge and act on family advice as to a sensitivity to a drug is not the first failure of this type to be considered at an inquest.
''I have commented about hospital failures in a previous inquest finding. The fact that SDHB did not document the advice given [by me] and act on this advice did place Neville Scully at risk.''
Mr Crerar recommended his finding into Mr Scully's death be considered by Southland Hospital, and by the SDHB generally, to assist with staff training.
''It is hoped that there will be no repeat of the circumstances which may have contributed to the death,'' he said.
